FORM 2729 Revised 2/17 FOLE

ARIZONA GAME AND FISH DEPARTMENT5000 W Carefree Hwy

Phoenix, AZ 85086-5000 APPLICATION FOR PIONEER LICENSE R12-4-201

FOR DEPARTMENT USE ONLY

Yes NoPlastic CardDenied:Approved:

Approved By:_______________________________

Drivers License Passport Birth Certificate ID card License # PR

Date card issued

Date Received: _______________ Region: ___________

Date:_____________

*Optional: Hard Plastic permanent card may be purchased for $4.00. Card will be mailed within 30 days after application is processed. The Arizona Game and Fish Department may issue a complimentary Pioneer License to individuals 70 years of age or older who have been bona fide residents of Arizona for 25 or more consecutive years immediately preceding application for the license. All other stamps and tags must be purchased separately.

FEE: NONE

Department ID Number or SSN:

Applicant's Signature*

Name Mailing Address

Eyes Hair Height WeightGender Phone ZipState City

Date of Birth

Physical Address (if different than mailing)

Email

*DO NOT SIGN THIS APPLICATION until you are in the presence of a Department employee or a notary public.This application must be notarized if it is not presented in person.

Date

Resident Drivers license or ID card #

R12-4-201 requires an applicant to submit an original or certified copy of their birth certificate, driver's license, Motor Vehicle Division ID card or U.S. Passport with their application. These items will be returned to the applicant. Photocopies are subject to verification.

[PLEASE PRINT OR TYPE]

Date AZ Residency began

By signing this document I affirm that I meet the eligibility requirements of this rule and the information provided on the application is true and accurate. I affirm that I am 70 years of age or older and have been a resident of AZ for 25 or more consecutive years preceding application for this license. I am not receiving any residency privileges in another state and the information provided on the application is true and accurate. It is unlawful for any person to obtain by fraud or misrepresentation a license to take wildlife. Any license fraudulently obtained is void from the date of issuance.

I do hereby certify that on this______day of _____________, ________ Applicant name___________________________ Personally appeared before me and made the above declaration. In witness whereof, I have hereunto set my hand and affixed my official seal.

Notary Public in and of the county of _______________, State of Arizona. My commission expires____________ Signature______________________________________

(seal)